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What is subdural hematoma?

Subdural hematoma is a hematoma that occurs below the dura mater (the outer protective covering of the brain) and the arachnoid mater (the middle layer of the brain).

Causes of subdural hematoma

Subdural hematoma is usually caused by subdural bleeding from tears in veins that cross the subdural space. The major cause is significant trauma to the head. Subdural hematoma can also occur in the elderly after apparently insignificant head trauma. Often, the patient doesn’t even remember the antecedent event. Much less common causes of subdural hematoma involve coagulopathies and ruptured intracranial aneurysms. Subdural hematomas have also been reported to be caused by intracranial tumors.

Physiology of subdural hematoma

Most of the time, subdural hematomas occur around the tops and sides of the frontal and parietal lobes. They also occur in the posterior cranial fossa, and near the falx cerebri and tentorium cerebelli. Subdural hematomas can expand along the inside of the skull, creating a concave shape that follows the curve of the brain, stopping only at the dural reflections like the tentorium cerebelli and falx cerebri.

Diagnosis of subdural hematoma

A physician begins the process of diagnosing a subdural hematoma by performing a thorough neurological and physical exam, including testing blood pressure, reflexes, vision, balance, and memory. To confirm hematoma, the physician may order blood tests, as well as performing tests using a CT (computed tomography) scan, a special x-ray machine that uses a computer to take pictures of your brain. More recently, MRI (magnetic resonance imaging) is also used to take the same imaging tests. Although usually not performed in acute subdural hematomas, where patients are typically unstable, MRI is the tool of choice for subacute and chronic hematomas. It is more accurate in identifying isodense chronic hematomas than the CT scan.

What would x-ray/MRI findings look like in a patient with subdural hematoma?
On a CT scan or MRI, subdural hematomas are crescent-shaped, with a concave surface away from the skull. Subdural blood can also be seen as a layering density along the tentorium cerebelli.

Types of subdural hematoma

Categorized according to speed of onset, there are basically three types of subdural hematoma: acute, subacute and chronic. Each type has distinctly different clinical, pathological, and imaging characteristics.

• Acute Subdural Hematoma. Acute SDH is a rapidly buildup subdural hematoma, usually occurs following head trauma. During impact, the brain moves around inside the skull. Veins may tear, spilling blood into the subdural space. Symptoms generally occur in the first 24 hours.
• Subacute Subdural Hematoma. Generally, subdural hematomas that have remained undetected or unoperated between 3-14 days after acute injury are referred to as subacute.
• Chronic Subdural Hematoma. It is a slow onset hematoma that can take several weeks after the first bleeding to buildup. This most commonly occurs as a result of a mild head injury that occurred at some time in the past. Chronic subdural hematoma is more common among the elderly. With age, the brain shrinks, increasing the space between the brain and the skull and allowing the tiny bridging veins to stretch and break.

Prognosis of subdural hematoma

The patient’s prognosis varies considerably from life threatening to minor effects, depending on the quantity of blood released and the severity of injury to other brain tissues. Prognosis also depends on how promptly and adequately treatment is received. Although large acute subdural hematomas (ASDH) are a severe medical emergency that have a high mortality rate, small subdural hematomas are reabsorbed over several weeks without much damage. Bigger hematomas may even in some cases gradually grow bigger although the bleeding has stopped. This enlargement increases pressure inside the skull and can compress the brain, possibly resulting in permanent brain damage or death if the blood is not drained away and the pressure relieved through surgical intervention.